The median nerve originates from the brachial plexus and innervates muscles in the forearm, wrist, and hand. It can be injured through trauma, compression syndromes like carpal tunnel syndrome, or tumors. Median nerve palsy is evaluated through history, physical exam including individual muscle testing and sensory exam, and electrodiagnostic studies. Management depends on the level and severity of injury and may include nerve repair, nerve grafting, tendon transfers, or nerve transfers to restore function over time. Prognosis depends on factors like the type and level of injury, age of the patient, and timing of treatment.
1.Anatomy
a.Course
b.Motor distribution
c.Sensory distribution
2.Common sites affected
3.Level of median nerve injury
4.Clinical feature with various test performed
5.Various syndromes related to median nerve
6.Treatment
7.Summary
anatomy of median nerve,course in arm and struthers ligament, branches in the forearm, carpal tunnel and course in hand, high and low median nerve injuries, principles of surgical management, pronator teres syndrome, anterior interosseous nerve syndrome, open and endoscopic carpal tunnel release
1.Anatomy
a.Course
b.Motor distribution
c.Sensory distribution
2.Common sites affected
3.Level of median nerve injury
4.Clinical feature with various test performed
5.Various syndromes related to median nerve
6.Treatment
7.Summary
anatomy of median nerve,course in arm and struthers ligament, branches in the forearm, carpal tunnel and course in hand, high and low median nerve injuries, principles of surgical management, pronator teres syndrome, anterior interosseous nerve syndrome, open and endoscopic carpal tunnel release
Injuries to the nerves of the upper limb can result from trauma, compression, lacerations, or certain medical conditions. Nerve injuries may lead to various symptoms, including pain, weakness, numbness, or loss of function in specific areas of the upper limb. Nerve injuries may range from mild to severe, and appropriate medical evaluation and treatment are essential. Physical therapy, splinting, medications, or in some cases, surgical intervention may be recommended based on the type and severity of the nerve injury. Early intervention is crucial for optimal recovery.
basic anatomy of the median nerve and its variants. pathology and different theories of the carpal tunnel syndrome plus the variations of the palmar cutanous branch of median nerve. types of skin incision for surgical intervention and difference between endoscopic and microscopic approaches.
PNI with Relevant Anatomy, Etiology, Mechanism of Degenration and Regenration, Saddon's and Sunderland Classifications, Clinical symptoms and Examination (Tests) of Brachial Plexus, Radial & Median Nerve.
Basics of patellofemoral instability for postgraduates. Gives brief introduction about patellofemoral joint anatomy, causes, examintaion and treatment for patellofemoral instability
Surgical Approaches to Acetabulum and PelvisBijay Mehta
Important surgical approaches to acetabulum and pelvis are described.
Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
Telegram: bmksupplier
signal: +85264872720
threema: TUD4A6YC
You can contact me on Telegram or Threema
Communicate promptly and reply
Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
3. Anatomy of Median Nerve
• Mixed nerve
• Runsin the median plane
of the forearm , so its
called median nerve
• Also calledlabourer’s
nerve.
Anatomy of aperipheral nerve
4. Anatomy of Median Nerve
• The median nerve has
contributions from entire
brachial plexus(C5-T1)
• Formed by Lateral(C5,C6,C7)and
Medial(C8,T1) Roots of lateral and
medial cord of brachial plexus
respectively.
5. • After originating from the
brachial plexus in the axilla, the
median nerve descends down
the arm, initially lateral tothe
brachial artery.
• Halfway down the arm, thenerve
crosses over the brachial artery,
and becomes situated medially.
Anatomy of Median Nerve
6. • No branches in the arm
• In the proximal 3rd – lies between
coracobrachialis anteriorly and long head
of triceps posteriorly
• In the middle 3rd – lies between the biceps
brachi anteriorly and long head of triceps
posteriorly
• In the distal 3rd – lies anteromedial
to brachialis muscle and
posteromedial to biceps brachi.
Anatomy of Median Nerve
Course in the Arm:
7. • In the antecubital fossa, the median nerve lies
deep to the bicipital aponeurosis, medial to
the antecubital vein and brachial artery.
• Gives 4 motor branches to-
• Pronator Teres
• Flexor Carpi Radialis
• Palmaris Longus
• Flexor Dig. Superficialis
Anatomy of Median Nerve
Course in the Elbow:
8. At the level of the junction of the two heads
of the pronator teres, the median nervegives
off the anterior interosseous nerve about 5-8
cmdistal tomedialepicondyle.
It courses down the forearm deep to the
flexor digitorum superficialis and superficial
to the flexor digitorum profundus.
In the distal 1⁄3 of the forearm, the median
nerve emerges from beneath the flexor
digitorum superficialis to lie medial to the
flexor carpi radialis and lateral to the
palmaris longus, before entering the carpal
tunnel.
Anatomy of Median Nerve
Course in the Forearm:
9. Anatomy of Median Nerve
• AIN gives branches to :
• Flexor Digitorum Profundus to Index and
Middle Fingers
• Flexor Pollicis Longus
• Pronator Quadratus
• The median nerve also gives a palmar
cutaneous branch, 4 to 5 cm proximal to the
wrist that provides sensation to thenar skin of
the palm.
10. • Within the carpal tunnel: the median nerve
lies immediately palmar and radial to flexor
digitorum tendons and dorsal to transverse
carpal ligaments.
• It gives Recurrent motor branch from the radial
surface – supplies
• Flexor Pollicis Brevis(Superficial Head)
• Abductor Pollicis Brevis
• Oppenens Pollicis
1/7/2019
Anatomy of Median Nerve
Course in the Wrist and Hand:
11. • After exiting carpal tunnel, it splits into two
terminalbranches-theradialandulnardivision
• Radial Division- Common Digital nerve to the
thumb and ProperdigitalNervetoRadialside
ofIndexFinger.
• Ulnar Division- Common digital nerve to
index/middlefingerandmiddle/ringfinger
• The digital nerves also supply 1st
and 2nd Lumbricals
Anatomy of Median Nerve
12. Motor Supplies
superficial volar forearmgroup
• Pronator teres
• Flexor carpiradialis
•Palmaris longus
•Flexor digitorum superficialis
• Deep group
•Flexor digitorum profundus (lateral)
• Flexor pollicis longus
• Pronator quadratus
• Hand
• 1st and 2ndlumbricals
• Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis
1/7/2019
Anatomy of Median Nerve
13. Sensory innervations
The median nerve is
responsible for the
cutaneous innervation of part
of the hand. This is achieved
via two branches:
Palmar cutaneous
branch
Palmar digital
cutaneous branch
16. LOW MEDIAN NERVE LESION
Causes:
I. Cutsin front of the wrist
II. Carpaldislocation
• Injury Distal to the innervation of forearm
muscles-i.e proximal to forearm
17. Sparing of the forearm muscles
Muscles of the hand paralysed
Anaesthesia over the median nerve
distribution in thehand
Thenar eminence is wasted and thumb
abduction and oppositionare weak
Sensation lost over the radial three and half
digits and trophic changesmay seen
LOW MEDIAN NERVE LESION
18. HIGH MEDIANNERVELESION
AXILLA
Crutch compression
Anterior shoulder dislocation
UPPER ARM- Stab
wounds
Ligament of struthers :
ELBOW
Supracondylar Humerus #
Fracture medial epicondyle
Elbow dislocation
• Injury Proximal to the innervation of forearm
muscles-i.e proximal to forearm
19. HIGH MEDIAN NERVE LESION
Wasting of musclesof forearm
Wasting of thenareminence
Weaknessof thumb abduction and opposition
Lossof abductor pollicis brevis +flexor pollicis brevis
Thehand is held with ulnar fingers flexed and index
finger straight (pointing sign) Lossof FDP
,FDS,FPL
Lost sensationat radial three and half digits
Weak Oksign
Ape handdeformity
21. Evaluation of Median Nerve Palsy
History
• Pain , Numbness or Weakness
• History of trauma
• Duration of symptoms
• Acute or chronic
• Associated injuries
43. ELECTROPHYSIOLOGICAL STUDY
potential (CMAP)
Electromyography
Todetermine completenessof anerve injury
Technique:
I. Very small needleis inserted into various muscle
II. Then,the signal is magnified by high gain amplifier
III. Finally, the reading are monitored via oscilloscopeand
recorded on the magnetic tape or paper recording
IV. Should performed 3-7daysafter peripheral nerve
Injury
V. It may showlow amplitude evoked compound muscle
44. Nerve Conduction Test
–First calculate thresholdby
stimulating on soundside
Measure Median motor and
sensory latencies andconduction
velocities across thewrist
Sensorylatency of greater than
3.5millisecondor amotor latency
of greater than 4.5 millisecond is
considered an abnormalfinding
Distal compound muscleaction
potential (CMAP)and sensory
nerve action potential (SNAP)
amplitudes may bedecreased
1/7/2019
45. PRINCIPLES OF SURGICAL
MANAGEMENT
1. Direct Injury: Nerverepair-
2. Long standingcases: Tendontransfers
Nervetransfers Nervegraft
3. Compressionneuropathies: Decompression
46. GENERAL INDICATIONS OF
SURGERY
In sharp injury- exploration for diagnostic as well as
therapeutic purpose .Neurorrhaphy can be done at time
of exploration or delayed
In avulsion or blast injury –to identify and suture
of nerve endsfor delayed repair
When anerve deficit follows blunt or closed trauma and
no clinical or electrical evedence of regeneration has
occurred after an appropriate time
47. Time of surgery
Primary repair within 6-8 hours gives best
results
Delayedprimary repair –between 7-18days
Secondary repair - 3to 6 weeks later preferable
in crushed ,avulsed , contaminated wounds
where patients life is seriously endangerd
48. SURGICAL TECHNIQUES
Coaptation
Approximating the cut ends of nerve in such a way
that motor fasiculi meets another motor fasiculi and
sensory tosensory
Conventionally done by 8-0 to 10-0 nylon
suture
Sutureless methods includes fibrin clots,
adhesive tapes ,collagentubulization
49. Neurorrhaphy
Neurorrhaphy is end to end suturing of nerve
Types
Partial Neurorrhaphy
EpineuralNeurorrhaphy
Perineural (fascicular)Neurorrhaphy
Epiperineural Neurorrhaphy
Interfascicular nervegrafting
52. Nerve grafting
Agap between cut ends
more than 2.5-4 cm is
indication of nerve graft
Nerves used forgraft
Most commonly suralnerve
Latral antebrachial cutaneousnerve
I n t e r fasc ic ula r nerve grafting
53. Critical Limit of Delay of Suture
Motor recovery in intrinsic muscles of the hand
does not occur if suture is delayed 9 months in
high lesionsor 12months in low ones.
Useful sensory recovery only rarely occurs after 9
months in high lesions or 12months in low ones but
it may occur when suture has been delayed aslong
as2years.
54. Reconstructive procedure
Tendon transfer
Motor recovery may not occur if the axons, regenerating at about 1
mm per day / 2-3 cm per month , don't reach the muscle within 18-
24 months of injury. In such circumstances , tendon transfers should
be considered.
When neighboring tendons are intact and if all criteria for
tendon transfer met ,then tendon transfer is treatment of choice
55. T
endon Transfer
Tendon transfer should be delayed for 6 months
a) Low MedianNerve:
- Re-routing of ring/ middle finger Flexor Digitorum Superficialis
to APBto aid thumb opposition
b) High MedianNerve:
- Suturing of profundus tendons to ring and small finger tendons
for restoration of IPjoint movements
56. Criteria for tendon transfer
Muscle power grade 5(preferably),if not atleast grade 4
Should haveits own nerveand blood supply
Synergisticgroup are chosenbecauseof easier rehabilitation
Diseaseshould not progress and infection to be controlled
Prior to transfer joint stiffness,contracture and malunion are
corrected
Tendontransferred should not be at anacute angle
57. Restoring thumb opposition:
Thumb opposition is a complex movement that involves palmar
abduction, pronation, and flexion of the thumb metacarpal and
proximal phalanx.
The ideal insertion for an opposition transfer is the APB
insertion. Insertion at this point most reliably causes the
combination of movements that result in thumb opposition.
The angle of pull should be from the location of the pisiform,
because this approximates the normal direction of pull of the
APB.
58. The Superficialis Opponensplasty
Involves dividing the ring finger FDSdistally in
the finger, retrieving the FDS proximal to the
carpal tunnel, re-directing the tendon distally
through the FPL sheath, and inserting it into
the thumb.
The main disadvantage of the superficialis
opponensplasty is that it can only be used in
cases of low median nerve palsy, because the
FDSis paralyzedin high median nervepalsy
59. The EIP(extensor indicis propius)
opponensplasty
The most commonly employed opposition transfer in high median
nervepalsy
The Huber Transfer
EmploysThe Ulnar Nerve-innervatedAbductor Digiti Minimi
(ADM) To Restore Opposition
Camitz Procedure
PLtransfer effectively restores palmarabduction, the
pronation and flexion components of opposition are not re-
established.
60. Tendon transfers
Other procedures
In cases of high median nerve injury, thumb IPJ flexion and index
finger DIPJ flexion can be restored with transfer of the BR, the
ECRL,or ECU.
The most common transfers are BR to FPL and ECRL to index
FDP
.
ECU re-routing and attachment to dorsal radius/Transfer of
biceps insertion from medial to lateral radius for weak forearm
pronation
62. Nerve transfers
Median recurrent neurotisation for high median
nervepalsy
Ulner-median nerve transfer(3rdlumbricle branch to
recurrent median nerve branch transfer)
Radial-median nerve transfer (PIN branches to
Recurrent median nerve branch transfer)
63. Sensory restoration for median nerve
Essential for fine motor tasks,motor recovery
is dependant on the quality of sensations, some
believe it aprerequisite for motor restoration
64. Nerve transfers
Nerve transfers for restoration of flexion in high
median nerve palsy ECRB branch of the radial
nerve to the AIN transfer without grafts
65. Prognosis
Prognosis of nerve regeneration dependsupon severalfactors
Typeoflesion:
Neuropraxia always recovers fully,axonotmesis may or may not,neurotmesis will not
unlessthe nerve isrepaired
Level oflesion
Thehigherthe lesion the worsethe prognosis
Typeofnerve
Purely motor or purely sensory nerves recover better than mixed nerves,because there is
less likelihood ofaxonal confusion.
Condition ofnerve ends
Nerve ends should be prepared in such away that satisfactoryfascicular pattern is
apparent in both proximal and distal stumps.
No scar, foreign material or necrotic tissue should be allowed to remain about the ends to
interfere with axonal regeneration.
66. Prognosis
Sizeofgap
Above the critical resection length ,suture is not successful
Age
Children do better than adaults .Old people do poorly
Delay insuture
The best results are obtained with early nerve repair, after few months , recovery following
suture becomes progressively lesslikely.
Associatedlesions
Damage to vessels , tendons and other structures makes it more difficult to obtain
recovery of auseful limb even if the nerve itself recovers.
Surgicaltechniques
Skill , experience and suitable facilities are needed to treat nerve injuries
68. Carpel Tunnel Syndrome
• It’s aclinical diagnosis
• Results fromcompression of
the median nerve at the
wrist
CTSFirst described by Sir JamesPaget
69. Anatomy - Carpal Tunnel
The bony borders are: radially,
the tubercle of the scaphoid and
the tubercle of the trapezium;
ulnarly the triquetrum, pisiform
and hook of the hamate.The
lunate lies in the floor of the
tunnel.
• 9 tendons runthrough the tunnel:
the 4 FDS, the 4 FDP
,and FPL.
FCR runs in aseparate fascial
compartment onthe radial sideof
the tunnel.
71. Clinical Features:
Hand and wristPain
Numbness and tingling in thumb and index and
middle fingers
Sparing ofPalmar cutaneous branch supply
Patient wakes at night with burning or aching
pain and shakes the hand to obtain relief and
restore sensation
Aggravatedby elevation of hand
Difficulty in holding on to a glass or cup
securely
Thenar atrophy and weakness of thumb
opposition and abduction may develop late
73. Signs of CTS
Thenar muscle wasting due to continued pressure
74. Phalen’s test
Phalen’stest
Patients is askedto
actively place the wrist
in complete but forced
flexion
+ve if tingling and
numbness is produced
in 60sec.
Sensitive and
specific in80%
75. Median Compression test/ Durkan’s
test
Median nerve
compression test
Direct pressure is exerted
over bothwrist 1st phase
–timetaken
for symptomsappear(15-
20sec)
2nd phase-time taken for
symptoms to disappear
after releaseof pressure
76. Tourniquet test
BPcuff tied proximal to elbow and inflated higher
than patient’s Systolic BP
.
+ve ifnumbness and paraesthesia
Scratch Collapse Test
Applyingastimulusovertheareaofnervecompression
whilethepatientisexertingB/Lshoulderrotation,transient
lossofmuscleresistanceresultinginarmcollapsing.
79. Steroid Injection
•Transient relief occurs in 80% of patients
after steroid injection
•But only 22% of patients with steroid
injections are pain free at 12months
(These patients were also splinted).
–It is most useful early in the disease,
when there has been less than 1yr of
symptoms
–there is no weakness or thenar atrophy
1/7/2019
80. Orthoses
Thefollowing orthoses help manage the carpal
tunnel syndromepain:
–Wrist handorthosis
–Thumb spicasplint
–Cock-up wristsplint
81. Orthotics goals
Decrease pain andswelling
Prevent deformity progression
PreventMovement
Byrestrict flexion movement of wrist
Main objective is to position wrist in neutral
but preferably slight extension to get
pressureoff of median nerve
82. SURGERY
Should be considered in patients with symptoms that do not
respond to conservative measuresand in patients with severe
nerve entrapment
It is important to note that surgery may be effective even if a
patient hasnormal nerve conduction studies
Methods ofSurgery
OpenCarpalTunnel Release
EndoscopicCarpalTunnel Release
85. Pronator Syndrome
-Proximal Forearm Compression
- BecauseOf:-
ligament ofStruthers,
Bicipital Aponeurosislacertus fibrosus,
Fibrous Band of pronator teresmuscle
-Due to repetitive and stenuous work with the arm in
pronated positin-computer workers and manual labourers
86. ClinicalFeatures:
Volar Forearm Pain
Sensorydisturbances
-Thumb & Index >Middle finger
Night pain is unusual and forearm pain ismore common
Hand numbness ongripping
Phalen’s testnegative
Symptoms provoked by resisted elbow flexion with
forearm supinated ( tightening of bicipital aponeurosis )-
Pronator Teres Test
88. Anterior Interosseous Syndrome
(Kiloh-Nevin Syndrome)
Involvement of theAnterior InterosseousNerve only
Causes
•Compression from Tumor or ganglion
•Tendons from flexor digitorum to flexor policis longus
•Accessoryhead of flexor policis longus (gantzer
muscle)
•Aberrant radialartery
89. Clinical Features:
Weaknessof the gripping movement of the thumb andindex finger( unableto
makeok -inability to flex either the thumb interphalangeal joint or the index-
finger distal interphalangeal joint
In contrast to those with pronator syndrome, thesepatients donot complain
of numbnessor pain
90. REFERENCES:
Last’s Anatomy, 12th Edition
Greens’ Operative Hand Surgery, 6th Edition
Apleys and Solomon’s System of Orthopedics
Miller’s Review of Orthopedics, 8th Edition
Ligament of struthers : It is seen 5 cm proximal to the medial epicondyle and is a fibrous band that interconnects a bony spur on the distal humerus to the medial epicondyle
Lesion Location: Proximal (near the elbow)
Deficiency: When the patient tries to make a fist, they are unable to flex the index and middle fingers due to loss of lateral lumbrical action, leading to the hand of benediction. The fingers are extended due to unopposed radial nerve action on the finger extensors.
Both flexor digitorum superficialis(FDS) and ProfundusFDP) of Index finger paralysed but in middle finger some amount of flexion is possible because of common muscle belly with ring and little finger
This lesion is related to ape hand due to the fact that loss of opponens pollicis means one has an unopposable thumb (like an ape). It seems some also believe the term ape hand refers to the thenar atrophy.
The patient’s forearm is extended and fully pronated. The patient is then instructed to resist supination of the forearm by the examiner.
The patient flexes the wrist along the trajectory of the forearm.
To test proximal interphalangeal joint flexion, the supinated forearm and hand are placed straight. Each finger is tested separately. Placing the fingers between the single finger to be tested and the remaining fingers that are immobilized isolates this movement. This maneuver places the finger to be tested in mild flexion at the metacarpal– phalangeal (knuckle) joint, and stabilizes the remaining fingers in extension, a position that allows isolation of the flexor digitorum superficialis.
To assess the median innervation of the flexor digitorum profundus one should concentrate on the index finger. To do so, holding the metacarpal-phalangeal and proximal interphalangeal joints immobile, and have the patient flex the distal phalanx against resistance.
Immobilize the thumb, except the interphalangeal joint, and then ask the patient to flex the distal phalanx against resistance.
A quick way to assess the flexor digitorum profundus and flexor pollicis longus innervation from the anterior interosseous nerve is to ask the patient to make an okay sign by touching the tips of the thumb and index finger together.
With weakness in these muscles, the distal phalanges cannot flex, and instead of the fingertips touching, the volar surfaces of each distal phalanx make contact
Have the patient resist supination of a fully flexed and pronated forearm. With full forearm flexion, pronation by the usually dominant pronator teres is minimized
Resist movement of the thumb away from the plane of the palm (palmar abduction),while stabilizing the metacarpals of the remaining fingers.
The patient flexes the thumb at the metacarpalphalangeal joint against resistance placed over both the proximal and distal phalanges.
Make certain the distal interphalangeal joint does not flex because in allowing this, substitution by the flexor pollicis longus occurs.
Use other hand to immobilize the first metacarpal to reduce substitution by the opponens pollicis.
Have the patient forcibly maintain contact between the volar pads of the distal thumb and fifth digit, while try to pull the distal first metacarpal away from the fifth digit. Although thumb opposition is only innervated by the median nerve, a combination of thumb adduction (adductor pollicis, ulnar nerve) and thumb flexion (flexor pollicis brevis, deep head, ulnar nerve) may mimic thumb opposition even when there is complete median nerve palsy present
Stabilize the patient’s index finger in a hyper- extended position at the metacarpal-phalangeal joint and then provide resistance as the patient extends the finger at the proximal interphalangeal joint.
Tested by gentle percussion along course of nerve from distal to proximal direction.
Tingling sensation felt by patient in distribution of nerve.
Tingling should persist for several seconds
This is most likely when there is a proximal injury in a nerve supplying distal muscles.
MNEMONIC
PRAGMATIC
P-PREGNANCY
R-RHEUMATOID ARTHRITIS
A-ATHRITIS DEGENERATIVE
G-GROWTH HORMONE EXCESS
i.e. ACROMEGALY
M-METABOLIC i.e. GOUT
A-ALCOHOLISM
T-TUMORS
I-IDIOPATHIC
C-CONNECTIVE TISSUE DISORDER i.e. AMYLOIDOSIS
Night numbness is caused by a number of factors:
Horizontal position results in a redistribution of fluid to the upper limbs
Drainage by the action of the muscle pump is
diminished
There is a tendency towards wrist flexion at night
The blood pressure drops during late night and early morning, resulting in decreased perfusion pressure
Differential Diagnoses of CTS:
Tendonitis
Tenosynovitis
Diabetic neuropathy
Kienbock's disease
Compression of the Median nerve at the elbow